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�C) <br /> 1. SEWAGE <br /> Distance to Public Sewers Connection necessary: iYes _ No _ •� <br /> Does existing septic system comply with Ord. /549: Yes v No Unknown <br /> If no, explain: <br /> Describe septic installation to be installed: <br /> Additional information or comments: <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes _ No _ Is well proper: Yes _ No <br /> State deficiency: <br /> Does existing or proposed use make this well public water: Yes _ No _ <br /> Sample of well water taken: Yes _ No Date Taken Results <br /> Additional information or comments: <br /> 3. GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes _ No Service Area No. =---- <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control: --- <br /> 5. AIR PO LLU TION PO TEN TILL <br /> State possible burning or processing pollutants & necessary control: <br /> 6. TOILET/HATH FACILITIES <br /> No. & location existing: Additional facilities needed <br /> 7. PREVIOUS OPERATION HISTORY . <br /> _� ✓ G!/7 O � .'( "�ter-!'/ --.,�`�.� ( .�.,� 'l' / X=' <br /> cs. <br /> GENERAL SAIIITATIO14 <br /> State any problems not previously noted: <br /> 9. POPULATION DENSITY <br /> Appx. No. People per sq. mi. <br />